Acute coronary syndrome is pathologically distinct in women and requires an appreciation of the specific risk factors, presenting symptoms, laboratory findings, and imaging results to treat correctly. Persistent disparities in mortality between men and women may be the result of failure to recognize and intervene, especially in the case of women aged less than 55 years. Protocols which establish criteria for activating the cardiac catheterization laboratory and which empower emergency department physicians to do so without delay show signs of eliminating disparities, as does guideline-directed therapy at the time of discharge from the hospital.